Integrated community health in Darfur: interacting with culture, dealing with insecurity

Health education and promotion is a process of learning and communication designed to improve health information, health literacy, health knowledge and life skills conducive to individual and community health. GOAL’s community health education and promotion programme in North Darfur applies this definition in a community-oriented education and outreach programme. The programme aims to improve beneficiaries’ health knowledge and practice, and to build capacity among local staff and beneficiaries.

An integrated approach: fine words, better practice?

GOAL runs an inclusive primary healthcare (PHC) programme encompassing curative care, clinics, water and sanitation and nutrition services for over 200,000 people in North Darfur. Our community health education and promotion (CHEP) programme has become a crucial tool in maximising participation in the PHC by the local community.

The CHEP programme employs 40 community health promoters and 240 volunteers. In conjunction with local communities, community health committees have been established, and these play an active role in the planning and provision of health care. The CHEP team delivers health messages on specific topics over a 2–4-week period, and seeks to tie these in with programme activities in other areas. Role plays, focus groups, school visits and distributions of soap/mats are among the activities and methodologies used. Topics such as sanitation and hygiene, malaria, HIV/AIDS, breast-feeding and the correct use of medication are also addressed.

Providing services and resources is a key aspect of health education and promotion. Education takes place at all static sites, including primary healthcare clinics, distribution sites and water points provided and maintained by GOAL. For example, at distributions, nutrition workers stress to beneficiaries the importance of returning every two weeks for services. To increase the perceived benefits of the programme, mothers are encouraged to think of therapeutic feeding, not just as food, but also as treatment for a sick child. Supplementary feeding is provided in conjunction with clinic services, located in or near the grounds of a local health centre. This encourages the idea that supplementary feeding programmes constitute medical treatment, and allows easy referral between health and nutrition services. CHEP staff continuously sensitise and mobilise communities, and provide locally appropriate nutritional education.

Insecurity: meeting needs, overcoming constraints

One of the most important factors in the successful provision of nutrition and healthcare services in insecure and remote areas like North Darfur is community awareness and education. Because agencies are limited in their direct access to communities, following up with beneficiaries is difficult.

The Darfur Peace Agreement (DPA) has had a direct impact on all GOAL programme activities. The agreement was signed on 5 May between the Sudanese government and one rebel faction, the Sudan Liberation Movement/Army (SLM/A). The SLM/A has a powerbase just to the north of GOAL’s area of operation. Since the signing of the DPA, 13 aid workers have died in conflict-related violence, more than were killed since the Darfur conflict began in February 2003. At least two new anti-DPA rebel alignments have emerged: the Darfur Redemption Front and the G-19, just north of GOAL’s base in Kutum. Command lines have fragmented, reducing agencies’ operational scope and making day-to-day security analysis difficult.

This insecurity has affected health education and promotion. For example, locally based CHEP staff conduct home visits to follow up on children absent from SFP or community-based therapeutic care (CTC) services, and to conduct health awareness-raising. Since the DPA was signed, CHEP staff have been unable to travel and it is impossible to provide general health services. As the political situation becomes more divisive and contested, regular communication with local communities will only become more difficult, as will securing the collaboration of the local Sheikhs, who are effective agents for CHEP in their own right, given their standing and authority among communities. One of the core elements of GOAL’s nutrition planning and provision – a comprehensive household nutrition survey in October 2005 – was only possible because we had effective communication, pre-survey security analysis and clear security guarantees.

As a discrete entity, CHEP has inherent advantages over other programme activities in insecure areas. Insecurity means that target populations can be displaced and/or rendered inaccessible, which increases and varies the health risks they are subjected to, compromises ongoing community health education and adds to the challenges of future health education work. With successful training of staff and local capacity-building, CHEP activities can be maintained in the event that insecurity hinders humanitarian access. Locally based and decentralised community health workers can sometimes continue practicing when core staff movements are limited by insecurity. CHEP does not rely on the guaranteed presence of highly skilled or technically oriented core staff in all areas of operation. That said, unless CHEP is linked with other areas of activity, a successful intervention is difficult to maintain because health messages are delivered during PHC clinic hours or as part of SFPs. This compromises the integrated nature of CHEP work.

Culture: benefits and barriers

GOAL’s community health and education programme operates from the premise that understanding one’s own culture and that of one’s clients is crucial to implementing effective education and outreach work. To that end, together with and as a complement to its ongoing education and outreach work, GOAL is producing a handbook on cultural health practices, agreed with local community leaders, and their interaction with GOAL’s programme activity in primary healthcare, nutrition and water and sanitation.

One aspect of this work has been to uncover the cultural ‘rootedness’ of various practices. For example, despite the prevalence of kitan (female genital mutilation) some accounts refer to this as an imported practice, only coming to Darfur in Sudan’s post-independence era, as centralised authority was installed in Khartoum. Whether this means the practice can be eliminated in North Darfur remains to be seen. A key avenue is to use and maximise the effects of group activity. Peer roles and the impact of peer groups are crucial. In an ordered society, these offer both challenges and platforms for action.

Tang-tang is a tradition whereby a sharp implement is used to cut a child’s palate or gums, in the belief that the puncture releases a poison believed to cause teething or tonsillitis. The integrated approach has made a clear impact in addressing this negative cultural health practice. Treatments for tonsillitis are given at primary healthcare clinics, and information campaigns discuss the positive impact of conventional treatment and the negative impact of tang-tang.

GOAL research has found that community attitudes to diarrhoeal disease in children are complex, and need to be understood before conventional treatment, such as oral rehydration (ORS), can be applied. Local treatments such as boiled guava were seen by the majority of respondents as the first and most appropriate treatment, and very few (19%) thought that ORS was necessary. The CHEP programme alerted other programme areas that a viable locally sourced remedy for diarrhoeal disease was available, and that this could be used in conjunction with ORS, pending further community education about ORS and clinical treatment for the condition.

Ultimately, people are part of their community: the choices they make are influenced by factors such as government, socio-economic status, culture and faith. While GOAL does not directly apply value judgments to cultural issues, a focus on practical applicability within the framework of GOAL’s other programme activities can promote discussion and change among local communities, when it can be shown that certain practices contradict the clear and perceived benefits of primary healthcare, medication, therapeutic and supplementary feeding and clean water provision.

Simon Roughneen is GOAL’s roving Media/Advocacy Officer. He worked in Darfur in February–July 2006. His email address is sroughneen@goalireland.com. Sam Fox worked as GOAL Community Health Manager in Kutum, North Darfur from September 2005 to June 2006. Thanks to GOAL Health Advisor Sinéad O’Reilly and Sudan (North) Acting Country Director Rob Kevlihan for valuable comments on an initial draft of this article.